Management of Heel Pad Degloving Injury After Severe Foot Crush Injury: A Case Report Study

Abstract

Crush injuries of the foot and ankle are uncommon and they have a poor prognosis leading to some form of disability. Degloving injuries of the heel and foot after crush injuries are rare and very challenging to manage due to the need for reconstruction of both osseous and soft tissue architecture. We present a salvage strategy for an open injury to the foot with extensive soft tissue detachment from the plantar and dorsal surface. A 30-year-old man was transferred to the Emergency Department from a neighboring hospital with a crush injury to the foot that had resulted in a degloving injury of the heel pad, after a motorcycle accident. The patient had a 20 cm circumferential wound that was extending from dorsal to the plantar surface along with rupture of the extensor digitorum longus (EDL) tendons and transection of the superficial peroneal nerve. There was an extensive detachment of soft tissues from the deep fascia and bones, whereas the posterior tibial artery was intact. In radiographic imaging, a small inferior avulsion fracture of the calcaneus along with fractures of the cuneiform bones was revealed. The initial management involved thorough surgical debridement, removal of necrotic tissues, repair of EDL tendons and fracture stabilization. Negative-pressure wound therapy was also applied for six weeks. Subsequently, a split-thickness skin graft was used to cover the skin defect. Six months after injury, the patient had a normal range of motion, intact sensation over the sole and could ambulate independently. Although the majority of heel pad degloving injuries have a poor prognosis, there are positive prognostic factors as presented in the current case for a satisfying functional final outcome, which include vascular intergrity, fracture stabilization, soft-tissue reconstruction with negative pressure wound therapy, and application of skin grafts.

Complete avulsion of the heel pad with talar and calcaneal fracture: salvage with multiple K-wire anchorage, internal fixation and free ALT flap

“…We are aware of only few reports of successful reattachment of the sole of the foot. These procedures require an intact tibial neurovascular bundle, as well as the connection to remaining soft tissue bridges [ 1 , 3 , 12 , 14 , 15 ].…”

“…However, considering the aim of tissue reconstruction, following the rule to replace like with like tissues any reconstruction of the plantar sole with alternative tissue is less than optimal [ 15 ]. Due to the lack of durability of the reconstructed tissue and the failure to provide a stable weight-bearing area, skin grafts, fasciocutaneous or muscle flaps are prone to soft tissue complications like atrophy, hyperkeratosis, instability, ulceration, resulting in chronic heel pain and a disturbed gait [ 7 , 12 ].…”

“…After simple suturing of the sole complications like wound breakdown, infection and flap necrosis have been reported [ 18 – 20 ]. Anecdotally, promising results have been achieved with anchorage of the heel pad with the use of multiple K-wires or anchor fixation in partial avulsions [ 1 , 12 , 14 ].…”

Repair of avulsion flap injury of heel by multiple point anchorage using Kirschner wires-a case series

“…In general, the majority of studies reported poor prognosis leading mostly to amputations particularly when there is a complete subcutaneous detachment. 9 The mechanism of injury is an important factor affecting treatment outcomes. The external forces of injury are initially concentrated on the back of the heel when a retrograde avulsion injury occurs, but as the shear stress decreases, the surrounding vascular network and chambers filled with fat are less severely affected.…”

Adult Traumatic Heel Pad Avulsion Repair with Polydioxanone Suture, Sterile Buttons, and Wound Vac-Assisted Closure

“…The heel pad contains elastic fibrous septa enclosing fat cells to accept loading stresses during gait; therefore, preservation of this specialized structure is preferred 1 . Injuries to the heel pad carry a high morbidity and poor prognosis leading to some form of disability that can affect a patient's quality of life 2 .…”